APPLICATION FOR AAP CREDIT
·  GENERAL INFORMATION

The designation of AAP Credit ensures that the educational activity has been planned by, and appropriate for, pediatricians to enhance their knowledge and skills. The American Academy of Pediatrics (AAP) offers AAP Credit for CME activities sponsored by organizations that are accredited to designate AMA PRA Category 1 Credit(s)™. The sponsoring organization is obligated to comply with ACCME Essentials and Standards and the requirements for granting AMA PRA Category 1 Credit(s)™ for CME activities. Activities receiving AAP Credit are listed in the AAP CME Finder at www.pedialink.org in the AAP Approved Credit CME Activities area. This provides significant visibility for an organization’s educational activities, since CME Finder is the premier resource for AAP member pediatricians to plan their CME. Also, AAP Candidate Members and Fellows who participate in AAP approved or sponsored CME activities may claim those credits against the AAP CME/CPD Award. This award is granted to Candidate Members and Fellow pediatricians who complete at least 150 credits over a 3-year period.

An application must be completed for each activity.

Credit may be granted on one application for multiple offerings of the same activity in a calendar year.

Allow 14 days for the review and approval of the application. Payment must accompany each application in order for it to be processed.

Information on all continuing medical education activities for which AAP Credit is sought must be provided on the application form with detailed responses attached as needed.

Review and designation of AAP Credit will only be given for those activities that are eligible for AMA PRA Category 1 Credit(s)™.

At least one member of the group planning the continuing medical education activity must be a member pediatrician of the AAP (national organization) and FAAP status. This person’s AAP ID number and signature are required, as noted on the application form.

Questions regarding the application process should be directed to the:

American Academy of Pediatrics

Division of Continuing Medical Education

Phone: 800/ 433-9016 ext. 7653

E-mail:

·  PROMOTIONAL MATERIALS

Applications must be submitted a minimum of 6 weeks prior to the promotion of the activity, so that the AAP Credit designation may be listed in your promotional materials. Retroactive approval is NOT possible. No references may be made to the AAP Credit system prior to the actual notification that AAP Credit has been awarded. Do not state “AAP Credit applied for” or similar wording, since this is contrary to AAP policy.

Upon written authorization from the AAP, the credit statement in all brochures and printed publicity MUST be worded as described in the approval letter.

The credit statement, received upon approval, is the only reference that can be used regarding the American Academy of Pediatrics. Granting of AAP Credit does not confer the ability to use the AAP name, Della Robbia or any other AAP trademark or similar references in your course materials or brochures.

·  PROCESS FOR ATTENDEES TO RECEIVE AAP CREDIT

AAP Credit for attendees is recorded only when an attendee submits a copy of his/her certificate of attendance, with AAP ID number, to the American Academy of Pediatrics. We encourage you to notify your attendees of this process so that AAP Credits may be accurately recorded on members’ transcripts. The address to mail the certificate is:

American Academy of Pediatrics

Attn: Transcript Coordinator

141 Northwest Point Blvd.

Elk Grove Village, IL 60007-1098

FAX: 847/434-8387

AAP Credit is only recorded if the physician is a member of the AAP or a PediaLink subscriber.

·  FEES

The AAP has established a non-refundable fee of $400.00 for each activity and $100.00 for each additional offering of the same activity in a calendar year. These fees cover the costs associated with AAP Credit review and maintenance of records. Checks or credit card information must accompany the application.

  1. Checks: Make check payable to the American Academy of Pediatrics and send along with the application to: 37925 Eagle Way, Chicago, IL 60678-1379.
  2. Credit Card Payment: Complete the information below and Mail with the completed application to: American Academy of Pediatrics, AAP Transcripts, 141 North West Point Blvd., Elk Grove Village, IL 60007. Please note credit card payments can only be submitted via mail or provided over the phone. Fax and email payments will not be accepted as our systems are not encrypted and we would like to secure your personal data.

·  PLEASE NOTE

Applications submitted without checks or credit card information cannot be processed until received.

Credit Card Payment:

Name of organization: ______

Complete Address: ______

Card Type: ______

Card Number: ______3-digit Security Code______

Expiration Date: ______

Amount to be charged to card: ______

Signature of Card Holder: ______

FOR AAP USE ONLY:

Batch # ______Date: ______Initials: ______

AAP Credit Application

(Please print or type)

(please select one)

______Live Educational Activity ______Self-Paced Activity

Sponsoring Organization:______

Address:______

City/State:______Zip:______

Phone Number:______

Organization website address:______

Ø  Indicate contact information you would like posted on CME Finder (if different than above):

______

CME Activity Director: ______

AAP Member* pediatrician on planning committee:

AAP Member Name:______

AAP Member ID number: ______

Address (City/State):______

Phone Number: ______

Signature: ______

*AAP member must be FAAP status

Name of person completing form: ____________

Telephone number: ______

FAX number: ______

e-mail:______

AMA PRA Category 1Credit(s)™ accreditation information:

Name of accrediting institution for AMA PRA Category 1 Credit(s)™:

Name:______

Address:______

City/State:______ZIP:______

Number of AMA PRA Category 1 Credit(s)™: ______

Complete the following information for the continuing medical education activity for which you are requesting AAP Credit. All requested information must be provided for each activity in order for this application to be processed. Attach separate sheets as necessary.

Activity title:______

v  Date(s): ______

v  Location (meeting site): ______

v  Complete Address:______

v  City/State:______Zip:______

Educational Objectives: Important note: In order for your CME activity to get maximum exposure on our CME Finder website, you must describe your primary objectives, using as many of the Content Categories as appropriate from the list included with this application. This will enable pediatricians to locate your CME activity when they search by educational content. Please send an e-mail with these objectives attached in a Word document to: and attach or list them below.

Upon completion of this CME activity the participant should be able to:

1)______

2)______

3)______

Indicate the percentage of participants you anticipate will be pediatricians: ______%.

q  Attach a copy of the preliminary program(s) including topics, faculty (or authors, for self-paced activities) and credentials, time schedule, breaks, and accreditation statement.

q  Attach a copy of the sponsoring organization’s Certificate of Accreditation

q  Attach a copy of your evaluation instrument. If your evaluation instrument is not yet developed, state briefly the techniques and/or procedures you propose to use to evaluate the effectiveness of the activity.

Indicate commercial supporters (if any):______

______

·  FOLLOW-UP MATERIALS:

Within 8 weeks after the completion of each activity, copies of the following materials MUST be mailed to the address on the front of the application.

Live Activities

v  Final Program (Brochure) including information regarding accreditation, Category 1 Credit

and AAP Credit information

v  Final Registration List (total number of participants and number of pediatricians must be indicated)

v  Certificate of Attendance (or completion)

v  Evaluation Summary

Self-Paced Activities

v  Copy of final and supporting materials (CD-ROM, workbooks, etc.)

v  Final List of Participants

v  Certificate of Participation

v  Evaluation Summary

IMPORTANT NOTICE TO APPLICANTS

The AAP reserves the right to revoke, rescind or refuse its credit at any time for any one or more of the following causes, or for any other reason which the AAP determines in its sole discretion is sufficient cause for refusal, revocation or rescission of AAP credit:

·  inclusion in the activity of incorrect, inappropriate, or incomplete clinical, scientific or medical/legal information or of commercially biased information

·  inclusion in the activity of content that is not based on the highest level of available evidence

·  a determination by the AAP that the activity does not comply with the ACCME Essentials & Standards for Commercial Support or with any of the requirements for AMA PRA Category 1 Credit(s)™ for CME Activities

·  misuse and/or misrepresentation of the AAP credit statement, name or logo

·  evidence that offers, promotions or services advertised with respect to the activity are not provided as advertised or otherwise promised

Any action in connection with the activity that the AAP deems inappropriate and/or any member complaints received by the AAP regarding the quality, etc. of the activity will be fully investigated by the AAP and may result in loss of AAP credit to a provider previously approved to designate such credit in connection with the activity. Revocation or rescission of AAP credit shall be effective immediately upon the provider’s receipt of written notice from the AAP.

SUBMISSION OF INCOMPLETE APPLICATIONS OR FAILURE TO PROVIDE ADDITIONAL INFORMATION REQUESTED MAY JEOPARDIZE AAP CREDIT DESIGNATION.

The activity director, by signing this application, attests that the activity complies with the ACCME Essentials and Standards for Commercial Support and that they have read and understand the above statements.

______

SIGNATURE OF CME ACTIVITY DIRECTOR DATE

______

SIGNATURE OF PERSON COMPLETING THIS APPLICATION DATE

LF\ 6008668.1

Content Categories for CME Finder

Please select the categories you wish to be used as keywords in CME Finder

1.  Adolescent Health 53. Neurology

2.  Adoption 54. Neurosurgery

3.  Advocacy 55. Nutrition/Breast Feeding

4.  Allergy and Immunology 56. Ophthalmology

5.  Alternative Medicine 57. Orthopaedics

6.  Anesthesiology 58. Otolaryngology

7.  Behavioral Pediatrics 59. Pain Medicine

8.  Bioethics 60. Patient Safety

9.  Cardiac Surgery 61. Perinatology

10.  Cardiology 62. Pharmacology

11.  Child Abuse & Neglect 63. Plastic Surgery

12.  Childcare 64. Poison Prevention

13.  Children with Special Health Care Needs 65. Practice Management

14.  Communication/Media 66. Psychiatry

15.  Community Pediatrics 67. Psychosocial Issues

16.  Complementary Medicine 68. Pulmonology

17.  Computers 69. Quality Improvement

18.  Critical Care 70. Radiology/Imaging

19.  Culturally Effective Pediatric Care 71. Research

20.  Daycare 72. Rheumatology

21.  Dental/Oral Health 73. School Health

22.  Dermatology 74. Sexual Abuse

23.  Developmental Pediatrics 75. Sports Medicine

24.  Disabilities 76. Substance Abuse

25.  Disaster Preparedness 77. Surgery

26.  Disease Prevention 78. Telephone Care

27.  Emergency Medicine 79. Terrorism

28.  Endocrinology 80. Transplantation

29.  Environmental Health 81. Transport Medicine

30.  Epidemiology 82. Urology

31.  Fluids and Electrolytes 83. Violence

32.  Foster Care

33.  Gastroenterology

34.  Genetics

35.  Health Care Financing

36.  Health Promotion

37.  Hematology/Oncology

38.  Home Health

39.  Hospital Medicine

40.  Humanitarian Assistance

41.  Immunization

42.  Infectious Diseases

43.  Information Technologies

44.  Injury/Violence

45.  International Child Health

46.  Integrative Medicine

47.  Leadership

48.  Medical Education

49.  Mental Health

50.  Metabolism

51.  Neonatology

52.  Nephrology

7

7/11/2014